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L37 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CIWMf181(New <br /> Survey Form - Page 1 1 4 - 1 0 0 6 2 <br /> CIWMB 181(New nage <br /> 4104) <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: '. 3 S $ D ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ,` _� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By - Inspector <br /> t. .4, G _ p <br /> Physical Address 3 / / C' 1 •+-e !.7 <br /> / S S <br /> 1770 � <br /> � Inspection Date / Z I <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> a 3 ®PM 0 PM <br /> —— -- — - --Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) . <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t ®Active ®Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 9 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Mi >r, <br /> O Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ax x <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> x <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days , x <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years n as x <br /> O O <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers .��. <br /> �r <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O 1 O 1 Other: <br /> Comments �rl�� CtQ�p Io--tg—ysr_�.S.S•�_�e�'�Y—. �-^ <br /> 5,T 79 449 os- �'GS�g ca/ �--7 2 <br /> Inspection Form Included: qQ�/ <br /> Comments Included:Q As <br /> �Re. Slgnatiu,._ <br /> Phone Number Ins tor's Signa ure _ Phone Number <br /> INSTRUCTIONS ON BACK F t�� Vit}( �{ p ( g 2 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA © . <br /> 0600604..6 215 <br />